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Available online at www.sciencedirect.com

Resuscitation
journal homepage: www.elsevier.com/locate/resuscitation

European Resuscitation Council Guidelines 2021:

Systems saving lives

Federico Semeraro a, * , Robert Greif b , Bernd W Böttiger c , Roman Burkart d ,

Diana Cimpoesu e , Marios Georgiou f , Joyce Yeung g , Freddy Lippert h ,
Andrew S Lockey i , Theresa M. Olasveengen j , Giuseppe Ristagno k ,
Joachim Schlieber l , Sebastian Schnaubelt m, Andrea Scapigliati n ,
Koenraad G Monsieurs o
a
Department of Anaesthesia, Intensive Care and Emergency Medical Services, Maggiore Hospital, Bologna, Italy
b
Department of Anesthesiology and Pain Medicina, Bern University Hospital, University of Bern, Bern, Switzerland, School of Medicine, Sigmund
Freud University Vienna, Vienna, Austria
c
Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
d
Interassociation of Rescue Services, Bern, Switzerland
e
University of Medicine and Pharmacy Gr.T. Popa Iasi, Emergency Department, Emergency County Hospital Sf. Spiridon, Iasi, Romania
f
American Medical Center Cyprus, Nicosia, Cyprus
g
Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
h
Copenhagen Emergency Medical Services, University of Copenhagen, Copenhagen, Denmark
i
Emergency Department, Calderdale Royal Hospital, Halifax, UK
j
Department of Anesthesiology, Oslo University Hospital, Norway
k
Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy, Department of Anesthesiology, Intensive Care and
Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
l
Department of Anaesthesiology and Intensive Care, AUVA Trauma Centre Salzburg, Salzburg, Austria
m
Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
n
Institute of Anaesthesia and Intensive Care, Catholic University of the Sacred Heart, Fondazione Policlinico Universitario A. Gemelli, IRCCS,
Rome, Italy
o
Emergency Department, Antwerp University Hospital and University of Antwerp, Edegem, Belgium

Abstract
The European Resuscitation Council (ERC) has produced these Systems Saving Lives guidelines, which are based on the 2020 International
Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include chain of survival, measuring
performance of resuscitation, social media and smartphones apps for engaging community, European Restart a Heart Day, World Restart a Heart, KIDS
SAVE LIVES campaign, lower-resource setting, European Resuscitation Academy and Global Resuscitation Alliance, early warning scores, rapid
response systems, and medical emergency team, cardiac arrest centres and role of dispatcher.

cardiac arrest patients not as a single intervention but as a

Introduction and scope system-level approach. The aim of this chapter is to provide
evidence-informed best practice guidance, about interventions
The Systems Saving Lives chapter describes numerous and which can be implemented by healthcare systems to improve
important factors that can globally improve the management of outcomes of out-of-hospital and/or in-hospital cardiac arrest

* Corresponding author.
E-mail address: f.semeraro@ausl.bologna.it (F. Semeraro).
https://doi.org/10.1016/j.resuscitation.2021.02.008
Available online xxx
0300-9572/© 2021 European Resuscitation Council. Published by Elsevier B.V. All rights reserved

Please cite this article in press as: F. Semeraro, et al., European Resuscitation Council Guidelines 2021: Systems saving lives,
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RESUS 8901 No. of Pages 18

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(OHCA and IHCA). The intended audience of the chapter are
governments, managers of health and education systems,
healthcare professionals, teachers, students and laypeople.
The concept behind the Systems Saving Lives approach to
cardiac arrest is to emphasise the connections between the
different individuals involved in the chain of survival. Citizens
are involved through cardiac arrest awareness campaigns (e.g.
European Restart a Heart Day - ERHD and World Restart a Heart
- WRAH) and may be engaged by apps as first responders. The
dispatch centre that receives the alert call activates the
Emergency Medical System (EMS) vehicle. Whilst the EMS
vehicle is en-route the call operator provides pre-arrival
instructions to start cardiopulmonary resuscitation (CPR). This
chapter also describes the concept of a cardiac arrest centre and
emphasises the importance of measuring the performance of
resuscitation systems. The key role of track and trigger systems
to avoid preventable cardiac arrest and the part played by rapid
response teams is described.
In the past, the guidelines of the ERC have been developed from a
perspective of an ideal high-resource or high-income environment. Little
attention has been paid to the applicability of statements from such areas
in the daily practice of lower-income regions. In many parts of the world, a
high-resource standard of care is not available due to a lack of financial
resources. For example, low-quality performance of EMS can be a barrier

Fig. 1 – System saving lives infographic summary.

Please cite this article in press as: F. Semeraro, et al., European Resuscitation Council Guidelines 2021: Systems saving lives,
Resuscitation (2021), https://doi.org/10.1016/j.resuscitation.2021.02.008
RESUS 8901 No. of Pages 18
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to guideline implementation. Internationally valid recommendations
should serve as a supportive structure for weaker systems.1
The Systems Saving Lives concept emphasises the interconnec-
tion between community and EMS (e.g. KIDS SAVE LIVES) and
should be implemented in each European community. Systems
Saving Lives ranges from the young student who learns CPR at
school, to a citizen who receives a cardiac arrest alert through their
mobile phone and is willing to start CPR and to use an automated
external defibrillator (AED) on the scene, to the EMS team that
continues advanced treatment to stabilise and transport the patient for
post-resuscitation care in a high-performance hospital. In Systems
Saving Lives, everyone and everything is an important link to survival
we are moving from the classical four-link chain of survival to a
multitude of links encompassed in the new System Saving Lives
concept. Every single step in this complex system is important.
These guidelines were drafted and agreed by the Systems
Saving Lives Writing Group members. The methodology used for
guideline development is presented in the Executive summary.1a
The guidelines were posted for public comment in October 2020.
The feedback was reviewed by the writing group and the
guidelines was updated where relevant. The Guideline was
presented to and approved by the ERC General Assembly on
10th December 2020.
Key messages from this section are presented in Fig. 1.
Concise guideline for clinical practice
Chain of survival & the formula of survival
 The actions linking the victim of sudden cardiac arrest with survival
are called the chain of survival.
 The goal of saving more lives relies not only on solid and high-
quality science but also effective education of lay people and
healthcare professionals.
 Systems engaged in the care of cardiac arrest victims should be
able to implement resource efficient systems that can improve
survival after cardiac arrest.
Measuring the performance of resuscitation systems
 Organisations or communities that treat cardiac arrest should
evaluate their system performance and target key areas with the
goal to improve performance.
Social media and smartphones apps for engaging the
community
 First responders (trained and untrained laypersons, firefighters,
police officers, and off-duty healthcare professionals) who are
near a suspected OHCA should be notified by the dispatch centre
through an alerting system implemented with a smartphone app or
a text message.
 Every European country is highly encouraged to implement such
technologies in order to:
 Improve the rate of bystander-initiated cardiopulmonary
resuscitation (CPR).
 Reduce the time to first compression and shock delivery.
 Improve survival with good neurological recovery.
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XXX 3
European Restart a Heart Day (ERHD) & World Restart a Heart
(WRAH)
National resuscitation councils, national governments and local
authorities should:
 Engage with WRAH.
 Raise awareness of the importance of bystander CPR and AEDs.
 Train as many citizens as possible.
 Develop new and innovative systems and policies that will save
more lives.
KIDS SAVE LIVES
 All schoolchildren should routinely receive CPR training each year.
 Teach CHECK - CALL COMPRESS.
 Trained schoolchildren should be encouraged to train family
members and friends. The homework for all children after such
training should be: "please train 10 other people within the next two
weeks and report back".
 CPR training should also be delivered in higher education
institutions, in particular to teaching and healthcare students.
 The responsible people in the Ministries of Education and/or
Ministries of Schools and other leading politicians of each
country should implement a nationwide program for teaching
CPR to schoolchildren. Training schoolchildren in CPR
should be mandatory by law all over Europe and elsewhere.
Community initiatives to promote CPR implementation
 Healthcare systems should implement community initiatives
for CPR training for large portions of the population
(neighbourhood, town, region, a part of or a whole nation).
Low-resource settings
Resuscitation research in low-resource settings
 Research is required to understand different populations,
aetiologies and outcome data of cardiac arrest in low-resource
settings. Research should follow Utstein guidelines.
 The level of income of countries should be included in reports. A
useful system to report level of income is the definition of the World
Bank (gross national income per capita).
 When reporting about resuscitation systems and outcome, psycholog-
ical and sociocultural views on cardiac arrest should be documented.
 Experts from all resource backgrounds should be consulted
concerning local acceptability and applicability of international
guidelines and recommendations for resuscitation.
Essential resources for resuscitation care systems in low-
resource settings
 A list with essential resuscitation care resources that is specially
adapted to low resource settings should be developed in
collaboration with stakeholders from these low resource settings.
European Resuscitation Academy and Global Resuscitation
Alliance
 Programmes such as the European Resuscitation Academy
programs should be implemented to increase bystander CPR
rates and improve survival in case of OHCA.
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Role of dispatcher
Dispatch-assisted recognition of cardiac arrest
 Dispatch centres should implement standardised criteria and
algorithms to determine if a patient is in cardiac arrest at the time of
the emergency call.
 Dispatch centres should monitor and track their ability to recognize
cardiac arrest and continuously look for ways to improve
recognition of cardiac arrest.
Dispatch-assisted CPR
 Dispatch centres should have systems in place to make sure call
handlers provide CPR instructions for unresponsive persons not
breathing normally.
Dispatch-assisted chest compression-only compared with
standard CPR
 Dispatchers should provide chest compression only CPR
instructions for callers who identify unresponsive adult persons
not breathing normally.
Early warning scores, rapid response systems, and medical
emergency teams
 Consider the introduction of rapid response systems to reduce
the incidence of in-hospital cardiac arrest and in-hospital
mortality.
Cardiac arrest centres
 Adult patients with non-traumatic OHCA should be considered
for transport to a cardiac arrest centre according to local
protocols.
Evidence informing the guidelines
Chain of survival & the formula of survival
The Chain of Survival for victims of out-of-hospital cardiac arrest
(OHCA) was initially described by Friedrich Wilhelm Ahnefeld in
1968 to emphasise all the time-sensitive interventions (represented as
links) to maximise the chance of survival.2 The concept was built upon
in 1988 by Mary M Newman of the Sudden Cardiac Arrest Foundation
in the United States.3 It was subsequently modified and adapted by
the American Heart Association in 1991.4
Designs depicting the chain of survival have been updated
frequently, but until recently the message conveyed in each link has
remained unchanged. The European Resuscitation Council (ERC)
chain of survival in its current format was first published in the 2005 ERC
guidelines and summarizes the vital links needed for successful
resuscitation: 1. Early recognition and call for help to prevent cardiac
arrest and to activate the EMS; 2. Early bystander CPR - to slow down
the rate of deterioration of the brain and heart, and to buy time to enable
defibrillation; 3. Early defibrillation - to restore a perfusing rhythm; and 4.
Early advanced life support and standardised post-resuscitation care,
to restore quality of life. The chain emphasises the interconnection and
the need for all links to be fast and effective in order to optimise the
chances of intact survival. Most of these links apply to victims of both
primary cardiac and asphyxial arrest.5,6
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XXX
Early recognition and call for help
The first link indicates the importance of recognising patients at risk
of cardiac arrest and calling for help in the hope of preventing
cardiac arrest. Most patients show signs of physiological deteriora-
tion in the hours before cardiac arrest or have warning symptoms for
a significant duration before cardiac arrest.7,8 Thus, chest pain
should be recognised as a symptom of myocardial ischaemia.
Recognising the cardiac origin of chest pain, and calling the
emergency services before a victim collapses, enables
the emergency medical service to arrive sooner, hopefully before
cardiac arrest has occurred, thus leading to better survival.9,10 Once
cardiac arrest has occurred, recognising cardiac arrest can be
challenging. Both bystanders and emergency medical dispatchers
have to diagnose cardiac arrest promptly to activate the chain of
survival. Early recognition is critical to enable rapid activation of the
EMS and prompt initiation of bystander CPR. ILCOR and the ERC
BLS guidelines highlight the key observations to diagnose cardiac
arrest are that the person is unresponsive with absent or abnormal
breathing.11,12
Early bystander CPR
The immediate initiation of CPR can double or triple survival from
cardiac arrest.13 21 The emergency medical dispatcher is an
essential link in the chain of survival to help bystanders initiate
CPR. Emergency medical dispatchers are increasingly being trained
to recognise cardiac arrest, to instruct and assist bystanders in
initiating resuscitation, and to support bystanders in optimising
resuscitation efforts, while awaiting the arrival of professional
help.22 31
Early defibrillation
The benefits of early defibrillation on survival and functional
outcome, though public-access defibrillation programs and
greater accessibility and availability of AEDs in the community,
are unquestionable. 32,33 These benefits have been attributed to
the decreased time to defibrillation by bystanders versus EMS
because survival in shockable OHCA decreases significantly
with each minute of delay in defibrillation. Defibrillation within
3 5 min of collapse can produce survival rates as high as
50 70%. This can be achieved only by public access programs
and onsite AEDs. 34 37 Each minute of delay to defibrillation
reduces the probability of survival to discharge by 10 12%. The
links in the chain work better together: when bystander CPR is
provided, the decline in survival is more gradual and averages
3 5% per minute delay to defibrillation.9,13,38,39
Early advanced life support and standardised post-
resuscitation care
Advanced life support with airway management, drugs and
correction of causal factors may be needed if initial attempts at
resuscitation are unsuccessful. Prior studies suggested no addi-
tional benefit from ALS in previously optimised EMS systems of
rapid defibrillation.40 A recent prospective study comparing the
association of ALS care with OHCA outcomes in more than
35,000 patients, showed that early ALS was associated with
improved survival to hospital discharge.41 Better quality of treatment
during the post-resuscitation phase with urgent coronary angiogra-
phy, optimisation of both circulation and ventilation, targeted
temperature management, multimodal neuroprognostication, and
subsequent rehabilitation, improves outcome.42,43
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The chain of survival in its current format focuses on specific
interventions rather than on the potential for the effectiveness of each
link. The contribution of each of the four links diminishes rapidly at
each stage as the number of patients decrease with progression along
the chain. Thus, a different view of the chain of survival has been
proposed to emphasise the relative contribution made by each link to
survival.44 Thus, to improve survival, greater focus should be placed
on early recognition and early CPR, and less to post-resuscitation
care. This new view of the chain of survival will help to inform clinicians,
scientists and researchers of where there is the greatest potential to
improve outcome and may provide renewed focus on research,
education and implementation, as depicted in the formula for
survival.45
The chain of survival was extended to the formula for survival
because it was realised that the goal of saving more lives relies not
only on high-quality science but also on effective education of lay
people and healthcare professionals.45,46 Ultimately, those who are
engaged in the care of cardiac arrest victims should be able to
implement resource-efficient systems that can improve survival after
cardiac arrest.
In the formula for survival, three interactive factors, guideline
quality (science), efficient education of patient caregivers (education)
and a well-functioning chain of survival at a local level (local
implementation), form multiplicands in determining survival from
resuscitation.
Science is recognised as an integral part of the other two factors:
education and implementation. Given the nature of resuscitation,
high-quality scientific evidence from randomised controlled trials is
often difficult to obtain and in many cases extrapolations from
observational studies are needed. There is also difficulty in applying
the same standards of evidence to educational recommendations
as to treatment recommendations. Resuscitation education pro-
viders and designers of teaching programs should create learning
experiences highly likely to result in acquisition and retention of
skills, knowledge and attitudes required for good performance. The
formula for survival concludes with local implementation. The
combination of medical science and educational efficiency is not
sufficient to improve survival if implementation is poor or absent.
Frequently, this implementation will also require some form of
change management to embed new visions into a local culture.
Quite often, the easy fix will not be the sustainable solution and
prolonged negotiation and diplomacy may be needed. A prime
example of this is the implementation of CPR training in the school
curriculum. In many cases, countries that eventually achieved this
goal spent years campaigning and persuading governments to
adopt this strategy.47,48
Measuring the performance of resuscitation systems
These ERC recommendations are informed by the ILCOR systematic
review, consensus on science and treatment recommendations on
system performance.49 System performance improvement is defined
as hospital-level, community-level or country-level improvement
related to structure, care pathways, process and quality of care.
According to ILCOR, two types of outcomes indicators should be
considered for measuring system performance improvement: critical
(survival with favourable neurological outcome at discharge and
survival to hospital discharge) and important (skill performance in
actual resuscitations, survival to admission and system level
variables).
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XXX 5
ILCOR recommends that organisations or communities that
treat cardiac arrest should evaluate their performance and target
key areas with the goal of improving performance. (Strong
recommendation, very low certainty of evidence). The systematic
review published by ILCOR recognises that the evidence in
support of this recommendation comes from studies of mostly
moderate to very-low-certainty certainty, mainly non-randomised
controlled trials.49
The majority of these studies associated with system perfor-
mance improvement found that interventions to improve system
performance improved system level variables and skill performance
of basic life support (BLS) and advanced life support (ALS) in actual
resuscitations,50 61 leading to improved clinical outcomes following
out-of-hospital or in-hospital cardiac arrest. Several studies showed
improved survival to hospital discharge52,54,56,57,61 70 and survival
with favourable neurological outcome at discharge.52,54,61 65,68 71
Some studies have shown an association between system
performance improvement and survival to admission64,67,69 but
others have not.53,71,72
We also recognise that interventions to improve system perfor-
mance need money, personnel and stakeholders, and in this context
some systems may not have adequate resources to implement
system performance improvement.
Further work needs to be done to:
 Identify the most appropriate strategy to improve system
performance.
 Better understand the influence of local community and organisa-
tional characteristics to improve system performance.
 Evaluate the cost-effectiveness of each intervention for improving
system performance.
Social media and smartphones apps for engaging the
community
Mobile phone technology is being increasingly used to engage
bystanders in out-of-hospital cardiac arrest (OHCA) events. The use
of mobile technology, including social media, cellular networks and
smartphone applications, could soon be of great impact. The rationale
for their use is that notifying citizens as first responders to an OHCA
event by a smartphone app with a Mobile Positioning System (MPS) or
Text Message (TM)-alert system could increase early CPR and early
defibrillation, thereby improving survival.
The ERC guidelines are informed by the ILCOR systematic review,
consensus on science and treatment recommendations, led by the
Education Implementation and Teams (EIT) Task Force. The review
investigated whether in the case of OHCA (P) alerting citizen first
responders through mobile-phone technology (I) compared with no
notification and standard EMS response (C) affects survival to hospital
discharge with good neurological outcome, survival to hospital
discharge, hospital admission, return of spontaneous circulation
(ROSC), bystander CPR rates, time to first compression/shock (O).49
The general direction of effect across most studies favours the use of
mobile phone technology to alert citizens as first responders in case of
OHCA. The rate of bystander-CPR was higher in the intervention
group than the comparison group in all studies.36,73 The rate of
survival to hospital discharge, was higher in the intervention group,73
76
but survival to hospital discharge with favourable neurological
outcome was no different between the intervention and the
comparison groups.73,76 Time to first compression/shock was shorter
in the intervention group in all the studies.74,76 78 After that ILCOR
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Treatment Recommendation was published, another six articles and a
systematic review were published, reinforcing the general direction of
effect in favour of the intervention.76,79 83 One study demonstrated
that increasing the density of AEDs and first responders alerted with a
text message, decreased time to defibrillation in residential areas
compared with the time to defibrillation by EMS personnel. The
recommended density of AEDs and first responders for the earliest
defibrillation is two AEDs/km2 and at least 10 first responders/km2.81 A
systematic review analysed 12 different mobile-phone systems to
alert citizens as first responders and found that first responders
accepted to intervene in a median 28.7% (interquartile range (IQR)
27 29%) of alerts and reached the scene after a median of 4.6 (IQR
4.4 5.5) minutes for performing CPR and after 7.5 (IQR 6.7 8.4)
minutes if an AED was first collected. First responders arrived
before EMS, started CPR and attached an AED in a median of 47%
(IQR 34 58%), 24% (IQR 23 27%) and 9% (IQR 6 14%) of cases,
respectively. Among those victims who had an AED attached by the
first responder, the first rhythm registered was shockable in a median
of 35% (IQR 25 47%) of cases. Pooled analysis confirmed the
general direction of effect in favour of the intervention as reported
above.82
A recent European survey performed under the umbrella of the
ESCAPE-NET project collected data about first responder treatment
after OHCA in Europe.84,85 Forty-seven (92%) OHCA experts from
29 countries responded to the survey. More than half of the European
countries have at least one region with a first responder system. First
responders in Europe are mainly firefighters (professional/voluntary),
police officers, citizens and off-duty healthcare professionals (nurses,
medical doctors, paramedics) as well as taxi drivers. The survey
reported that the use of an app with a mobile positioning system (MPS)
or Text Message (TM)-alert system was implemented in some
European countries (e.g. Austria, Czech Republic, Denmark, United
Kingdom, Germany, Hungary, Italy, Netherland, Romania, Sweden,
and Switzerland). Another survey was conducted from February 6th,
2020 to February 16th, 2020 to obtain a picture of available systems to
alert citizen first responders and locate the nearest AEDs across
Europe.86 The results covered 32 European countries. More than half
of the countries (62%) had at least one system in one region to alert
citizens as first responders for a total of 34 different systems. Almost all
systems (94%) required citizens to be trained in BLS to become part of
the first responder network. Systems to map and locate the nearest
AED were available in 25 European countries (78%). Given the
considerable variability across Europe, it would be appropriate to
pursue a uniform standard of development of these systems.
Moreover, a standardised approach like the Utstein Style is highly
encouraged to obtain a uniform reporting of these systems.
Smartphone-based activation of first responders to OHCA saves
lives. The statements generated by a recent consensus conference
involving five European countries may assist the public, healthcare
services and governments to use these systems to their full potential
and direct the research community towards fields that still need to be
addressed.87
In line with ILCOR, the ERC recommends that citizens who are
near a suspected OHCA event and willing to be engaged/notified by a
smartphone app with a mobile positioning system (MPS) or Text
Message (TM)-alert system should be notified (strong recommenda-
tion, very-low-certainty evidence). As these technologies become
ubiquitous, they will play a greater role in the chain of survival. A causal
relationship between application-initiated citizen responses and
survival has not been proven. Therefore, systems using such
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XXX
technologies should promote research and improve the quality of
data collection to further demonstrate the benefit of their integration
into the EMS. Privacy legislation, which has been cited as a barrier to
the implementation of such technologies, may have to be changed.
European Restart a Heart Day (ERHD) & World Restart a Heart
(WRAH)
Survival rates from OHCA around the world remain relatively low,
despite the development of guidelines and the influence of
technology.88 The exact magnitude of the burden of cardiac arrest
in Europe and worldwide is well documented.89 The ERC recognises
that an important strategy to increase survival rates from OHCA is to
increase the rate of bystander CPR. If more people were trained and
more AEDs were placed strategically, more lives could be saved from
cardiac arrest.37
Following a lobbying campaign by the ERC, the European
Parliament passed a Written Declaration in June 2012 with a majority
vote of 396 signatures calling for comprehensive training programmes
in CPR and AED use across all its member states. The Written
Declaration called for an adjustment of legislation in EU member
states to ensure national strategies for equal access to high-quality
CPR and defibrillation. The declaration also called for the establish-
ment of a European cardiac arrest awareness week. As a result of this,
and as part of its strategy to increase bystander CPR rates, the ERC
announced the establishment of an annual Cardiac Arrest Awareness
day on 16 October every year, to be named ‘Restart a Heart Day’. The
motto for the first European Restart a Heart Day (ERHD) in 2013 was
‘Children Saving Lives’. A survey conducted on behalf of the ERC
generated responses from 23 of 30 national resuscitation councils. It
identified that training in first aid incorporating CPR in the school
curricula existed in only 4 of the 23 responding countries.90 National
policies about resuscitation have the power to increase the willingness
of citizens to perform bystander CPR. The Restart a Heart initiative
actively encourages the development of national policies in all
member states throughout Europe.91
In 2018, the European Restart a Heart initiative was endorsed by
the International Liaison Committee on Resuscitation (ILCOR) and
has since taken a global dimension under the name of World Restart a
Heart (WRAH).92 94 The motto of WRAH is ‘All citizens of the world
can save a life all that is needed is two hands (CHECK CALL
COMPRESS)’. Each person trained is a potential lifesaver and the
number of additional people they inspire to also receive training is
unmeasurable. The results for WRAH 2018 exceeded expectations as
over 675,000 people were trained in CPR worldwide.95
For WRAH 2019, promotional videos were produced worldwide
in iconic places. Moreover, 191 National Red Cross Societies of the
five geographical zones of the world were invited to engage in the
campaign. The most impressive European results for 2019 were
reported from the United Kingdom, where 291,000 people were
trained in CPR. This was achieved by the participation of every EMS
organisation, as well as teaching delivered by medical students. The
subject has subsequently become mandatory in the English school
curriculum, as it is in five other European countries. This
demonstrates the power of the WRAH in helping to promote
change in national policy. In Poland, 150,562 people were trained, in
Germany 30,000, and in Italy 17,000. Overall, 493,000 people were
trained in CPR in Europe with over 5 million trained and up to
206 million reached by social media worldwide during WRAH
2019.94
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In conclusion, the ERC has made a significant impact with
ERHD and WRAH. In its first two years alone, WRAH has become
so influential that it has reached countries not yet represented by
ILCOR and it has already become so dynamic and viral that over
six million people have been trained in CPR. The purpose of
WRAH is that national councils use this initiative to promote
uniformity in practice and reporting systems, create benchmarks
and, by learning from each other, define weak links in the chain of
survival in order to improve healthcare practice. The low rate of
bystander CPR may signify the lack of public awareness as part of
the problem, thus justifying it as a high priority for the ERC.
Education of the public is an essential component of the strategy to
fight the burden of OHCA.
On the basis of expert consensus, it is recommended that national
resuscitation councils, national governments and local authorities,
engage with WRAH to raise awareness of the importance of bystander
CPR and AEDs, to train as many citizens as possible, and to develop
new and innovative systems and policies that will save more lives.
KIDS SAVE LIVES
Mandatory nationwide training of schoolchildren has the highest and
most important long-term impact for improving bystander CPR
rate.96,97 In the long run, this appears to be the most successful
way to reach the entire population.98 The highest bystander CPR rates
have been reported in some Scandinavian countries, where education
of schoolchildren in CPR has been mandatory for decades, and this
concept is starting to spread all over Europe and the world.16
Following several activities by the ERC, in 2015 the World Health
Organization (WHO) endorsed the ERC ‘KIDS SAVE LIVES’ a joint
statement from the International Liaison Committee on Resuscitation
(ILCOR), the European Resuscitation Council (ERC), the European
Patient Safety Foundation (EPSF), and the World Federation of
Societies of Anaesthesiologists (WFSA).99,100 This statement rec-
ommends two hours of CPR training annually from the age of 12 years
in all schools worldwide. At this age, children are more receptive to
instructions and they learn more easily to help others. It is accepted
that younger children, whilst physically unable to perform CPR, can
also learn the principles behind CPR as it provides a foundation for
their learning and they may still be able to instruct others to do so
instead.101 As a result, we recommend teaching all schoolchildren the
concept of CHECK-CALL-COMPRESS. Additional training can be
provided for ventilation and AED particularly for, but not limited to,
older children or teenagers.102 The legal requirement for CPR
education in schools across Europe is summarised in Fig. 2.
Starting at a young age also means that performing CPR becomes
like swimming or riding a bike: the skills are retained for a lifetime and
are easily refreshed even after a prolonged absence.103 It has been
clearly demonstrated in different studies that healthcare professio-
nals, teachers trained to teach CPR, students, peers and others can
successfully teach schoolchildren, and all can serve as multipliers.104
CPR knowledge and skills can be spread further by asking children
to teach their family and friends.102 Evolving experience indicates that
even children in the kindergarten and from the age of four years are
able to successfully recognise a cardiac arrest and call the EMS.105
Teachers can and should be qualified to teach schoolchildren in
CPR.102 Educating schoolchildren in resuscitation is performed in
several countries around the world.92,98,106 108 To date, education of
schoolchildren in resuscitation is mandatory by law in six countries in
Europe, and it is a recommendation in another 24 countries. However,
Please cite this article in press as: F. Semeraro, et al., European Resuscitation Council Guidelines 2021: Systems saving lives,
Resuscitation (2021), https://doi.org/10.1016/j.resuscitation.2021.02.008
XXX 7
implementation has not yet been achieved nationwide in all these
countries, all over Europe and the world. 48,94 CPR education for
schoolchildren may hugely improve public health, since lay resusci-
tation is the most important factor for high-quality survival following
sudden cardiac arrest.102
The principles of KIDS SAVE LIVES can be extended to higher
education institutions as well. Teacher training courses should include
tuition of CPR competencies to enable teachers to deliver CPR
education to schoolchildren.109 All healthcare students should get
high quality resuscitation education to enable them to teach CPR and
act as first CPR responders.97
Community initiatives to promote CPR implementation
The role of the community in providing the first response to OHCA
through bystander CPR is critically important but in most systems is
still far from optimal. Many interventions have been implemented to
improve the community response to OHCA and have been described
in other sections of these guidelines. Several initiatives have been
implemented with the aim to increase the engagement of the
community, which is the general population of a studied area (i.e. a
group of neighbourhoods, one or more cities/towns or regions, a part
of or a whole Nation), consisting of individuals with no specific duty to
respond.
ILCOR led a scoping review to identify relevant studies. Nineteen
studies were identified which described community initiatives
amongst the adult population only.
The main community initiatives identified were grouped in three
categories:
 Community CPR instructor-led training interventions.20,110 114
 Mass-media interventions.115,116
 Bundled interventions.16,56,117 125 The impact of the three groups
of community initiatives on specific outcomes can be summarised
as follows:
Instructor-led training
All the studies that implemented instructor-led training reported
bystander CPR rate as an outcome, with 67% of the studies showing
a benefit of the intervention.20,110,112,114 Survival to discharge was
reported in 83% of cases and improved in 40% of these
studies.20,114 Survival with good neurological outcome was reported
in 67% of these studies and showed benefit of the intervention in
only 25% of cases.112 ROSC was assessed in 33% of these studies
and in half of the cases showed improvement with the
intervention.114
Mass-media
The two studies assessing the impact of this type of intervention
reported only the outcome bystander CPR rate, with one study
showing benefit and the other showing no benefit.115,116
Bundled intervention
None of these studies reported survival with good neurological
outcome or ROSC. Survival to discharge was reported in 25% of these
studies and showed no benefit of the intervention.120,124 Bystander
CPR rate was reported in 89% of these studies, showing benefit in all
cases,56,117 119 except one.122
In conclusion, the only outcome that was assessed in almost
all the included studies was bystander CPR rate and almost all
the studies showed a benefit with the implementation of
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8 RESUSCITATION XXX (2021) XXX XXX

Fig. 2 – Kids save lives: legal requirement for CPR education in schools across Europe.

community initiatives. This benefit was more frequent when the discharge. Therefore, despite low certainty of evidence and
type of intervention was a bundle compared with instructor-led some conflicting results, we consider it worthwhile to implement
training or mass-media. Furthermore, there was a slight benefit community initiatives such as CPR training involving a large
(only 40% of studies that reported it) in survival at hospital proportion of the population or bundled interventions in order to

Please cite this article in press as: F. Semeraro, et al., European Resuscitation Council Guidelines 2021: Systems saving lives,
Resuscitation (2021), https://doi.org/10.1016/j.resuscitation.2021.02.008
RESUS 8901 No. of Pages 18
RESUSCITATION XXX (2021) XXX
improve the bystander CPR rate among laypersons in case of
OHCA.
Low-resource settings
In 2015, ILCOR published a systematic review on resuscitation
training in developing countries.126 This review showed that
resuscitation training in low-resource settings is well-received and
has significantly reduced the mortality of cardiac arrest However,
limited information is available about the outcome of resuscitation in
low-resource settings. A recent ILCOR scoping review of OHCA in
low-resource settings showed wide variability in outcomes.1 The
scoping review recommended future studies to be undertaken in
specific (sub-) populations and aetiologies of cardiac arrest including
paediatric cardiac arrest, traumatic cardiac arrest, cardiac arrest in
disaster or conflict zones, or even cardiac arrest in single neighbour-
hoods or areas within an otherwise high-resource setting.1
The definition of low resource settings varies. Therefore, a
comprehensive approach such as classifying countries according to
their gross domestic product (GDP) per capita based on the World
Bank definitions (https://data.worldbank.org) was applied.49
Considering the scarcity of resources in low-income coun-
tries, the feasibility of full ALS and post-resuscitation care is
controversial. There is debate whether it is ethically acceptable
that ALS for OHCA patients is not available in certain countries or
areas. 127 Moreover, longer-term outcomes such as 30-day
survival or neurological performance after cardiac arrest in
low-resource countries tend to be worse than those reported in
patients from high-resource countries.1,128 A list of essential
resuscitation equipment and resources like the 2009 World
Health Organization statement on the quality of trauma care may
help improving the chain of survival to improve outcome after
OHCA. 129
European Resuscitation Academy (ERA) and Global
Resuscitation Alliance (GRA)
The European Resuscitation Academy aims to improve survival from
cardiac arrest through a focus on healthcare system improvements that
bring the individual links in the chain of survival and the formula for
survival together. Entire EMS staff (managers, administrative and
medical directors, physicians, EMTs and dispatchers) from different
healthcare systems and countries are invited to learn from the ERA
Program (derived from the Seattle (US) based Resuscitation Academy
ten steps for improving cardiac arrest survival) together with the local
host health institutions.130 The ERA puts emphasis on defining the local
cardiac arrest survival rate by understanding the importance of
reporting data in a standardised Utstein template. Participating EMS
systems are encouraged to develop concrete measures to improve
cardiac arrest survival followed by appropriate measurements of these
action plans. ‘It takes a system to save a life’ summarises the essentials
(the core) of every Resuscitation Academy program globally - to
acknowledge that all medical science and educational efficiency won’t
result in positive outcomes from OHCA and IHCA itself without a clear
strategic plan to foster the local implementation in our systems. This is
reflected in the formula for survival in resuscitation. The Global
Resuscitation Alliances (GRA) mission is “to advance resuscitation
through the Resuscitation Academy model by accelerating community
implementation of effective programs through a quality improvement
strategy to measure and improve.”
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Resuscitation (2021), https://doi.org/10.1016/j.resuscitation.2021.02.008
XXX 9
Role of dispatcher
ILCOR recommends that dispatch centres implement a standardised
algorithm and/or standardised criteria to determine immediately if a
patient is in cardiac arrest at the time of the emergency call and to
monitor and track their diagnostic capability. ILCOR also recommends
that dispatch centres look for ways to optimise their sensitivity to
recognise cardiac arrest (minimise false negatives).11 This strong
recommendation was based on very-low certainty evidence drawn
from 46 observational studies which included 789,004 adult OHCAs
reporting recognition of arrest varying between 46% and 98% and a
specificity varying between 32% and 100%.27,28,79,131 172 The review
concluded that the studies were too heterogeneous for head-to-head
comparisons of different criteria, algorithms, dispatcher background
or training, and the diagnostic capabilities varied greatly within all the
various categories with no clear patterns emerging.
The strong recommendation for dispatch centres to implement a
standardised algorithm and/or standardised criteria to immediately
determine if a patient is in cardiac arrest despite very-low-certainty
evidence is outweighed by the benefits related to early recognition and
early bystander CPR. Further, ILCOR found the large variation in the
reported diagnostic capabilities across all systems to underline the
need for systems to monitor and track their diagnostic capabilities and
continuously look for ways to improve.
Consistent with ILCOR, the ERC recommends dispatch centres to
implement a standardised algorithm and/or standardised criteria to
immediately determine if a patient is in cardiac arrest at the time of
emergency call. The ERC supports the need for high-quality research
that examines gaps in this area.
Dispatch-assisted CPR
ILCOR recommends that emergency medical dispatch centres have
systems in place to enable call handlers to provide CPR instructions
for adult patients in cardiac arrest.22 This strong recommendation was
based on very-low certainty evidence drawn from 30 observational
studies; 16 studies comparing outcomes from patients when
dispatch-assisted CPR instruction was offered with outcomes from
patients when dispatch-assisted CPR instruction was not of-
fered23,31,135,140,148,151,153,173 181 and 14 studies comparing out-
comes from patients when dispatch-assisted CPR instruction was
received with outcomes from patients when dispatch-assisted CPR
instruction was not received.135,140,148,173 176,179,180
Six studies reported survival with good neurological outcome
when dispatch-assisted CPR instructions were offered compared
with when dispatch-assisted CPR instructions were not offered.
Survival with good neurological outcome at hospital discharge
(5533 patients) was higher among those offered CPR instructions
(relative risk (RR) 1.67 (95% CI 1.21, 2.31); p = 0.002).151,174
Survival with good neurological outcome at 1 month (44,698 pa-
tients) was higher among those offered CPR instructions (RR 1.09
(95% CI 1.03 1.15;p = 0.004).175,179,181 Survival with good neuro-
logical outcome at 6 months (164 patients) was not significantly
higher among those offered CPR instructions (RR 1.27 (95% CI
0.72, 2.27); p = 0.14).180
Five studies reported adjusted analysis for survival with good
neurological outcome when dispatch-assisted CPR instruction was
received compared with when dispatch-assisted CPR instruction was
not received.24 26,178,179 Survival with good neurological outcome at
hospital discharge (35,921 patients) was higher among those
receiving dispatch-assisted CPR compared with no bystander CPR
RESUS 8901 No. of Pages 18
10 RESUSCITATION XXX (2021) XXX
(adjusted odds ratio (ORadj) 1.54 (95% CI 1.35, 1.76)).24 26 Survival
with good neurological outcome at 1 month (4306 patients) was higher
among those receiving dispatch-assisted CPR compared with no
bystander CPR (ORadj 1.81 (95% CI 1.23, 1.76)).179
Survival with good neurological outcome at hospital discharge
(17,209 patients) was similar among those receiving dispatch-
assisted CPR compared with unassisted bystander CPR (ORadj
1.12 (95% CI 0.94, 1.34)).25 Survival with good neurological outcome
at 1 month (78,112 patients) was similar among those receiving
dispatch-assisted CPR compared to unassisted bystander CPR
(ORadj 1.00 (95% CI 0.91, 1.08)).178
The science evaluating the effect of dispatcher-assisted CPR is
complex as it compares outcomes for patients who have been offered
or received dispatch-assisted CPR with outcomes for both patients
who received no bystander CPR and patients who received
unassisted bystander CPR. Taken together, ILCOR found that these
studies supported dispatch-assisted CPR as outcomes are generally
better for patients who receive dispatch-assisted CPR compared with
no bystander CPR, and for some outcomes as good as unassisted
bystander CPR. ILCOR placed a greater value on studies providing
adjusted analysis, as cohorts of patients who received unassisted
CPR generally had more favourable prognostic characteristics, and
cohorts of patients who did not receive any bystander CPR generally
has less favourable prognostic characteristics.
Consistent with ILCOR, the ERC recommends emergency medical
dispatch centres have systems in place to enable call handlers to
provide CPR instructions for adult patients in cardiac arrest, and that
emergency call takers provide CPR instructions (when required) for
adult patients in cardiac arrest. The ERC supports research into the role
of new technologies such as locating and distributing AEDs and their
interphase with bystanders and first responders.
Dispatch-assisted chest compression-only CPR compared
with standard CPR
ILCOR recommends dispatchers provide instructions to perform
compression-only CPR to callers for adults with suspected OHCA.182
This strong recommendation was based on low-certainty evidence from
three randomised controlled trials which included 3728 adult OHCAs.183
185
Only one study reported the outcome survival with favourable
neurological outcome, and did not demonstrate any benefit of chest
compression-only CPR over standard CPR (RR 1.25 (95% CI 0.94, 1.66);
p = 0.13).184 [Rea 2010 423] Survival to hospital discharge was similarly
not significantly different (RR 1.20 (95% CI 1.00, 1.45); p = 0.05).183 185
In making these recommendations, ILCOR recognised that the
evidence in support of these recommendations was of low certainty and
performed at a time when the ratio of ventilations to chest compressions
was 15:2, which leads to greater interruptions of chest compressions
than the currently recommended ratio of 30:2. However, the signal from
every trial is consistently in favour of dispatch-assisted CPR protocols
that use a compression-only CPR instruction set. Reviewing the totality
of available evidence and considering current common practice,
training and quality assurance experiences, the ILCOR BLS task force
has kept the strong recommendation for compression-only for
dispatcher-assisted CPR despite low-certainty evidence. In making
these recommendations, ILCOR placed a higher value on the initiation
of bystander compressions, and a lower value on possible harms of
delayed ventilation.
Consistent with ILCOR, the ERC recommends that dispatchers
provide instructions to perform compression-only CPR to callers for
adults with suspected OHCA. The ERC supports high-quality
Please cite this article in press as: F. Semeraro, et al., European Resuscitation Council Guidelines 2021: Systems saving lives,
Resuscitation (2021), https://doi.org/10.1016/j.resuscitation.2021.02.008
XXX
research to address unresolved issues relating to optimal instruction
sequence, identifying key words, and the impact of dispatch-assisted
CPR instructions on non-cardiac aetiology arrests such as drowning,
trauma, and asphyxia in adults and children.
Rapid response systems including early warning scores and
medical emergency teams
Unwell patients admitted to hospital are at risk of deterioration and may
progress to cardiorespiratory arrest. Patients commonly show signs and
symptoms of deterioration for hours or days before cardiorespiratory
arrest.7 Rapid response systems (RRSs) are programs that are designed
to improve the safety of hospitalised patients whose condition is
deteriorating quickly.186 A successful RRS may be defined as a hospital-
wide system that ensures observation, detection of deterioration, and
tailored response to ward patients that may include rapid response teams
(RRTs), also called medical emergency teams (METs).187
The ILCOR treatment recommendation suggests that hospitals
consider the introduction of rapid response systems (rapid response
team/medical emergency team) to reduce the incidence of in-hospital
cardiac arrest and in-hospital mortality based on a systematic review
(weak recommendation, low-quality evidence).49 A total of 57 observa-
tional studies63,188 242 and 2 randomised trials243,244 were included in the
systematic review. There are low-certainty data to suggest improved
hospital survival and reduced incidence of cardiac arrests in those
hospitals that introduce a RRS, and a suggestion of a dose-response
effect, with higher-intensity systems (e.g. higher RRS activation rates,
senior medical staff on RRS teams) being more effective.
Consistent with ILCOR, the ERC suggests that hospitals consider
the introduction of a rapid response system (rapid response team/
medical emergency team) to reduce the incidence of IHCA and
in-hospital mortality.
Cardiac arrest centres
There is wide variation among hospitals in the availability and type of
post resuscitation care, as well as clinical outcomes.245,246 Cardiac
arrest centres are hospitals providing evidence-based resuscitation
treatments including emergency interventional cardiology, and
bundled critical care with targeted temperature management, and
protocolised cardiorespiratory support and prognostication.247,248
ILCOR suggests that wherever possible, adult patients with non-
traumatic OHCA cardiac arrest should be treated in cardiac arrest
centres.49,249 This weak recommendation is based on very low
certainty evidence from a systematic review that included 21 obser-
vational studies 250 270 and 1 pilot randomized trial.271 Of these,
17 observational studies were ultimately included in a meta-
analysis.250 256,261 270 This meta-analysis found that patients cared
for in cardiac arrest centres had improved survival to hospital
discharge with favourable neurological outcomes and survival to
hospital discharge. This survival benefit from care at cardiac arrest
centres did not extend to long term survival (survival to 30 days with
favourable neurological outcome and survival to 30 days).
The resulting ILCOR treatment recommendations included:22
 We suggest adult non-traumatic OHCA cardiac arrest patients be
cared for in cardiac arrest centres rather than in non-cardiac arrest
centres.
 We cannot make a recommendation for or against regional triage
of OHCA patients to a cardiac arrest centre by primary EMS
transport (bypass protocols) or secondary interfacility transfer.
RESUS 8901 No. of Pages 18
RESUSCITATION XXX (2021) XXX
Consistent with ILCOR, the ERC suggests that adult patients with
non-traumatic OHCA cardiac arrest be cared for in cardiac arrest
centres rather than in non-cardiac arrest centres. In 2020 the main
European organisations involved in OHCA reached a consensus that
patients with OHCA of presumed cardiac aetiology should be
transported directly to a hospital with 24/7 coronary angiography.272
Conflicts of interest
TMO declares research funding from Laerdal Foundation and Zoll
Foundation
BB declared speakers honorarium from Baxalta, BayerVital,
BoehringerIngelheim, ZOLL, FomF, Bard, Stemple, NovartisPharma
RG declares his role as Editor of the journal Trends in Anaesthesia
and Critical Care, associate editor European Journal of Anaesthesi-
ology. He reports institutional research funding.
GR declares his role of consultant for Zoll; he reports research
grant from Zoll for the AMSA trial and other Institutional grants: EU
Horizon 2020 support for ESCAPE-NET, Fondazione Sestini support
for the project “CPArtrial”, EU Horizon 2020 and also Coordination and
support for the action “iProcureSecurity”
AL reports his role of Medical advisor First on Scene training
company
AS declares research funding from EU Horizon 2020 for “I procure
security project”
JY declares research grants from National Institute for Health
Research and Resuscitation Council UK.
FL declares research funding from Laerdal foundation, Zoll
foundation, NovoNordic foundation and Danish Trygfonden.
Acknowledgement
The Writing Group acknowledges the significant contributions to this
chapter by Tommaso Scquizzato and Zace Drieda. TS and ZD gave
an important contribution in the social media and smartphones apps
for engaging the community paragraphs, in organising the European
survey about the use of apps, and in reviewing statistical analysis and
level of evidence. Thanks to Gavin D. Perkins and Jerry P. Nolan for
editorial oversight.
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